Patient engagement in HIV care encompasses a cascade of events from HIV diagnosis to retention in care. Each step is vital in achieving the goal of virologic suppression and improved health outcomes. Compromising this clinical imperative is the nearly 50% of HIV-infected individuals in the US who are not in continuous HIV care. The HIV epidemic poses a particularly severe problem in Hispanic populations. While Hispanics comprise 16% of the US population, they comprise 20% of new HIV infections. Immigrants make up 42% of new HIV diagnoses in Hispanics. Emerging interventions to improve retention in HIV care in the general HIV-infected population have not been adequately studied in Hispanic immigrants, a growing segment of the population where risk for poor outcomes is a precarious reality. Factors specific both to Hispanic cultures and to immigrant status are essential to highlight for effective intervention development. A better understanding of these factors could lead to improved, tailored approaches to retention in HIV care for Hispanic immigrants, improvement in health outcomes, and a reduction in ongoing HIV transmission. CANDIDATE: My specialized training in clinical infectious disease, public health, and Hispanic studies, coupled with extensive resources at Harvard University and Massachusetts General Hospital (MGH), uniquely position me to accomplish these aims. I have five peer-reviewed research articles directly related to HIV outcomes and the consequences of adherence to care in resource-limited settings, and extensive clinical experience caring for HIV-infected individuals as well as immigrants. RESEARCH: I will conduct formative qualitative research with Hispanic immigrants infected with HIV and their medical providers to understand factors (e.g. individual preferences, structural barriers) and agents (e.g. role of the family) that influence decision-making around retention in primary HIV care. I will give specific attention to generating novel intervention ideas to improve retention in HIV care through these in-depth interviews with patients and the multi-disciplinary providers within an HIV provider team including physicians, nurses, social workers, case managers, and community health workers (Aim 1). I will expand the Andersen Model of Health Services Use to include conceptual models of health disparities in order to evaluate societal, clinic/system- level, and individual determinants of HIV care utilization. Guided by this conceptual model, formative research, and community stakeholder feedback, we will identify the most significant and modifiable factors that determine retention in HIV care for the study population in order to inform the development of an intervention. We will develop and pilot test a culturally-tailored intervention (Aim 2). The intervention will target Hispanic immigrants who are not retained in HIV care, and for whom there are limited culturally relevant interventions. We will intervene at a particularly vulnerable period in the HIV care cascade, retention in care, where care interruption poses substantial consequences for both the individual, due to risk of clinical decline and risk-taking behaviors, and for public health, due threat of resulting HIV transmission. Standardization of the intervention will occur through iterative refinements based on participant and community advisory board feedback. Through a focused randomized pilot trial (Aim 3), we will further refine study procedures and perform preliminary power analyses in preparation for a larger, more definitive test of the intervention directed through submission of an R01 proposal at the end of the award. TRAINING/MENTORING: My long-term career goal is to become an independent investigator with expertise in developing culturally-tailored community-based interventions to improve outcomes in HIV and other chronic diseases for vulnerable populations. I will need rigorous training in methodologies that will enable me to fully capture factors, such as culture and context, and processes, such as acculturation, that influence use of HIV care for Hispanic immigrants. Training in community-engaged methods will facilitate effective development and deployment of novel interventions in the community setting. To complement my prior training in clinical care and HIV outcomes research, I have outlined a plan for intensive training in community-based participatory research, qualitative research, behavioral theory, and intervention development. This training will occur through graduate-level coursework as well as through intensive supervision with my mentors, who are internationally- recognized leaders in areas of research directly related to the proposal. My mentorship team also has a strong foothold in community-based partnerships for research and HIV care delivery in Massachusetts and nationally. Furthermore, this project advances the institutional strategic priorities of the CDC, NIMH and the Office of AIDS Research, notably, to reduce HIV health disparities and to improve medical care for people living with HIV. The successful completion of this research will position me as an expert in retention in care for HIV-infected Hispanic immigrants, and more generally will enable me to address challenges in vulnerable populations burdened with chronic illnesses that require innovative models for disease management.

Public Health Relevance

Of the 1.2 million HIV-infected individuals in the US, nearly 50% are not engaged in regular HIV care and 80% do not show viral load suppression, a marker of HIV treatment success. Among Hispanic patients with HIV, immigrants represent 40% of new HIV cases, an important public health disparity that reflects a confluence of ill-defined risks and barriers to health care. This Career Development Award will address the knowledge gap in barriers to retention in HIV care for Hispanic immigrants, and will leverage this information to develop and pilot test culturally-relevant approaches to improve retention in care, a critical yet underdeveloped area of public health research.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Mentored Patient-Oriented Research Career Development Award (K23)
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Behavioral and Social Science Approaches to Preventing HIV/AIDS Study Section (BSPH)
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Gordon, Christopher M
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Massachusetts General Hospital
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Levison, Julie H; Levinson, Julia K; Alegría, Margarita (2018) A Critical Review and Commentary on the Challenges in Engaging HIV-Infected Latinos in the Continuum of HIV Care. AIDS Behav 22:2500-2512
Levison, Julie H; Regan, Susan; Khan, Iman et al. (2017) Foreign-born status as a predictor of engagement in HIV care in a large US metropolitan health system. AIDS Care 29:244-251
Levison, Julie H; Bogart, Laura M; Khan, Iman F et al. (2017) ""Where It Falls Apart"": Barriers to Retention in HIV Care in Latino Immigrants and Migrants. AIDS Patient Care STDS 31:394-405
Levison, Julie H; Alegría, Margarita (2016) Shifting the HIV Training and Research Paradigm to Address Disparities in HIV Outcomes. AIDS Behav 20 Suppl 2:265-72
Cesar, Carina; Koethe, John R; Giganti, Mark J et al. (2016) Health outcomes among HIV-positive Latinos initiating antiretroviral therapy in North America versus Central and South America. J Int AIDS Soc 19:20684
Levison, J; Triant, V; Losina, E et al. (2014) Development and validation of a computer-based algorithm to identify foreign-born patients with HIV infection from the electronic medical record. Appl Clin Inform 5:557-70